In an increasingly competitive Medicare Advantage (MA) marketplace, Star Ratings have become more crucial than ever before.
Higher Star Ratings not only demonstrate care quality to current and potential members, they mean additional financial incentives from CMS in the form of bonus payments and rebates for superior quality and member/beneficiary service.
For example, one study shows that increasing a plan’s Star rating from 3 to 4 can result in an 8% to 12% increase in enrollment. With that bump in enrollment, an MA plan could potentially bring in millions of dollars in additional revenue in the form of bonuses and rebates. And, CMS now incentivizes high-performing MA plans with Quality Bonus Payments of 5% starting at 4 stars, with additional 5% bonuses once the plan hits the higher premium 4.5- and 5-Star Ratings.
Improving Star Ratings can be challenging, especially because many of the metrics that comprise the ratings are contingent on patient behavior, which can be difficult for plans to influence. Despite these complexities, healthcare organizations that administer MA plans can now directly address patient behavioral change by partnering with their providers to implement mobile-enabled remote patient monitoring (mRPM).
Through patients’ smartphones or other mobile devices, physicians can leverage mRPM to automatically check in with them to manage chronic conditions, or to monitor their progress when recovering from a procedure such as orthopedic surgery. mRPM also allows physicians to learn more about patients’ social determinants of health that may be hindering care plan adherence.
How mRPM can move the dial on behavior and adherence
By offering mRPM technology to providers, health plans can have a more immediate and direct influence over patient behavior and adherence. Whether it is Star ratings, HEDIS measures or any quality metric, managed care organizations can strengthen their financial performance while improving outcomes of their members.
Four ways that mRPM can be leveraged to improve performance and quality metrics such as Star ratings include:
1. Changing behaviors through consistent reinforcement
Star Ratings criteria can essentially be grouped into three distinct categories:
- Customer service issues. These include helping patients resolve disputes, answering questions and offering benefits and services based on beneficiaries’ needs.
- Doctor one-shots. This category includes one-time annual screenings or tests, such as mammograms, flu shots, colorectal exams and BMI assessments.
- Patient behavior and adherence. By far the most difficult category to influence, these metrics involve patients’ medication adherence, obtaining prescription medications, monitoring physical activity and overall management of chronic conditions.
Most MA plans have systems and resources in place to achieve high scores in the first two categories. For the third category, however, the majority do not offer a solution for network physicians to effectively communicate with patients, nor data collection methods that will move the needle positively on adherence and improved metrics.
2. Meeting patients where they are
My personal experience is one clear illustration of this issue. Recently, I received a form letter in the mail from my health plan reminding me to refill a specific medication before my prescription runs out. The letter, however, arrived at my home more than a week before I was permitted to get a refill. What action could I take? I did what the thousands of other health plan members likely did who received a similar reminder: tossed the letter in the recycling bin and forgot about it.
Improving care plan adherence needs to be “in the moment”—not an ill-timed paper reminder, a 10-minute office checkup, or a hospital discharge directing the patient to schedule a follow-up visit. Patient behaviors must be periodically and consistently influenced so that they will be engaged in healthier lifestyle behaviors, care plan adherence, preventive care and proactive communication with providers. To do that, insurers and providers need to consistently support patients in managing their chronic conditions at home and safely manage their care transitions.
Offering education, seeking feedback, and answering questions while patients are at home reminds them to adhere to their provider’s care plan, while also fostering greater engagement that motivates patients to take ownership of their health and improve their own outcomes.
The smartphone offers tremendous opportunities in this regard. According to Pew Research, 77% of adult Americans own a smartphone, including 46% of those aged 65 years and older. In addition, 73% of Americans aged 50 to 64 years own a smartphone, indicating that even more beneficiaries will have the devices for the foreseeable future.
3. Tapping into CMS’ Chronic Care Management program
Enhanced RPM of Medicare patients is already paying dividends for CMS through its Chronic Care Management (CCM) service program launched in 2015. The program allows physicians to earn additional reimbursement for non-face-to-face management of patients with two or more chronic conditions.
Adoption of the CCM program has been slow so far; in its first two years, only 684,000 beneficiaries received the service, according to a November 2017 two-year retrospective study. . However, CMS still saved $74 per beneficiary per month (PBPM) in the “18-month cohort” of the study, thanks to the enhanced monitoring and patient support. Surveyed patients also reported that they appreciated the CCM service and felt more engaged in their own health.